ORIGINAL RESEARCH
A Chinese Immigrant Paradox? Low Coronary Heart Disease Incidence
but Higher Short-Term Mortality in Western-Dwelling Chinese
Immigrants: A Systematic Review and Meta-Analysis
Kai Jin, MN, BN, RN; Ding Ding, PhD, MPH, BS; Janice Gullick, PhD, MArt, BFA, RN; Fung Koo, PhD, BHS, MPH, MHEd; Lis Neubeck, PhD, BA
(Hons), RN
Background-—Chinese form a large proportion of the immigrant population in Western countries. There is evidence that Chinese
immigrants experience an increased risk of coronary heart disease (CHD) after immigration in part due to cultural habits and
acculturation. This is the first systematic review and meta-analysis that aims to examine the risk of CHD in people of Chinese
ethnicity living in Western countries, in comparison with whites and another major immigrant group, South Asians.
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
Methods and Results-—Literature on the incidence, mortality, and prognosis of CHD among Chinese living in Western countries
was searched systematically in any language using 6 electronic databases up to December 2014. Based on the meta-analysis,
Chinese had lower incidence of CHD compared with whites (odds ratio 0.29; 95% CI: 0.24–0.34) and South Asians (odds ratio 0.37;
95% CI: 0.24–0.57) but higher short-term mortality after first hospitalization for acute myocardial infarction compared with whites
(odds ratio 1.34; 95% CI, 1.04–1.73) and South Asians (odds ratio 1.82; 95% 1.33–2.50). There was no significant difference
between Chinese immigrants and whites in long-term outcomes (mortality and recurrent events) after acute myocardial infarction.
Conclusions-—These findings provide an important focus for resource planning to enhance early secondary prevention of CHD to
improve short-term survival outcomes among Western-dwelling Chinese immigrants. ( J Am Heart Assoc. 2015;4:e002568 doi:
10.1161/JAHA.115.002568)
Key Words: Chinese • coronary heart disease • mortality • outcome
C
oronary heart disease (CHD) is a leading cause of
mortality and morbidity worldwide. In particular, CHD is
a major health problem in migrant populations in developed
countries.1 Research has shown that immigrants tend to have
a higher risk for CHD than the host population and the overall
prevalence, mortality, prognosis and risk factors of CHD vary
among subgroups of immigrants.2,3 Chinese are one of the
fastest growing migrant populations in Western countries
such as Australia, Canada, and the United States.4–6 The
From the Sydney Nursing School (K.J., J.G., F.K., L.N.) and Prevention Research
Collaboration, Sydney School of Public Health (D.D.), University of Sydney,
NSW, Australia.
Accompanying Appendices S1 and S2 are available at http://jaha.ahajournals.org/content/4/12/e002568/suppl/DC1
Correspondence to: Kai Jin, MN, BN, RN, Sydney Nursing School, Level 2,
Charles Perkins Centre, University of Sydney, NSW 2006, Australia. E-mail:
[email protected]
Received August 20, 2015; accepted October 25, 2015.
ª 2015 The Authors. Published on behalf of the American Heart Association,
Inc., by Wiley Blackwell. This is an open access article under the terms of the
Creative Commons Attribution-NonCommercial License, which permits use,
distribution and reproduction in any medium, provided the original work is
properly cited and is not used for commercial purposes.
DOI: 10.1161/JAHA.115.002568
number of Chinese immigrants increased by 54% in Australia
between 2006 and 2011 and by 43% in the United States
between 2000 and 2010, respectively.7,8
Chinese immigrants have both higher prevalence and
higher mortality rates from CHD compared with mainland
Chinese.9 Chinese immigrants also appear to have a higher
prevalence of cardiac risk factors such as hypertension and
diabetes after migrating to Western countries when compared
with Chinese living in China, and the risk increases with longer
length of residence.9–11 Although there is limited literature
comparing the absolute rates for mortality after acute
myocardial infarction (AMI) between Chinese people living in
China and Chinese immigrants in Western countries, a
Canadian study described higher short-term mortality in
Chinese immigrants (12.2%)12 compared to a study of Chinese
in mainland China (7%).13 Moreover, there is some evidence
that Chinese immigrants have a higher risk of mortality after
AMI despite their much lower incidence rates of AMI
compared to whites and South Asians.12
With an increasing number of Chinese immigrants in
Western countries, their health has become a key issue to
their host nations. While it is important to quantify the risks
associated with CHD to inform population health strategies,
Journal of the American Heart Association
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A Chinese Immigrant Paradox? Systematic Review
Jin et al
Methods
This systematic review and meta-analysis is guided by the
Preferred Reporting Items for Systematic Reviews and Metaanalyses Protocols and the Meta-Analyses of Observational
studies in Epidemiology criteria.17,18
Definition and Eligibility Criteria
Study subjects were Chinese and whites or South Asians
(defined based on self-reported ancestry) living in Western
countries including North America (United States, Canada),
Europe, Australia, and New Zealand. Chinese and South
Asian ethnicity were also identified by using surname
analysis, which is proven to have high sensitivity and
specificity.19,20 Chinese immigrants refers to Chinese born
in, or having ancestry from, mainland China, Hong Kong,
Taiwan, or Macao. South Asians refers to people from the
Indian subcontinent (India, Pakistan, Bangladesh, and Sri
Lanka) or those who self-identify as South Asians.16 Whites
were defined as people of European ancestry2 and in some
studies are described as Caucasians.12 For the purpose of
this review, CHD is defined as myocardial infarction (MI),
acute coronary syndrome, ischemic heart disease, or
percutaneous coronary intervention or coronary artery
bypass grafting surgery identified using International Classification of Diseases (9th edition code 410 and 10th edition
code I 21 and I 22).21
DOI: 10.1161/JAHA.115.002568
Inclusion and Exclusion Criteria
We included studies where the incidence or prognosis of CHD
was reported for Chinese immigrants and also for a comparison population (whites or South Asians). We only included
studies based on registries or administrative data because
these are not subject to selection or reporting bias.22
Exclusion criteria included studies on children, Chinese
immigrants living in non-Western countries, studies that did
not separate Chinese from other Asian groups and studies
that reported Chinese only without comparison with whites
and/or South Asians. We also excluded the studies that
reported composite outcomes including heart failure or
cerebrovascular disease, studies that only reported CHD
mortality from the general population, and studies that did not
use International Classification of Diseases codes to define
CHD. Case reports, editorials, expert opinions, and review
articles were also excluded. In the case of multiple studies
published based on the same data set, we selected the study
with the most in-depth analysis.
Search Strategies
A comprehensive search of primary studies was independently conducted by 2 reviewers (K.J. and D.D.) based on
search strategies developed by the research team. Databases
included PubMed, PsychInfo, CINAHL, Scopus, Web of
Science, and Cochrane library. In addition, we searched the
reference lists of included studies or relevant reviews as well
as the gray literature. We did not limit the search by study
design, date, or language. The specific search terms and
strategies are described in Appendices S1 and S2.
Selection of Articles and Quality Appraisal
All studies were imported to Endnote for screening. K.J. and
D.D. independently screened papers based on reading the
title, abstract, and full-text. The final results were reviewed by
all authors. The Newcastle-Ottawa Scale was selected to
guide a quality appraisal of these observational cohort
studies.23 Any discrepancies or disagreements were resolved
first by discussion between K.J. and D.D. and then by
consultation with the team.
Data Collection
All data were extracted by K.J. and were verified by D.D. When
results were not available in published papers, corresponding
authors of primary studies were contacted to clarify the
reported data. Study characteristics were summarized including country, follow-up period, the comparison group, age
range, sex, outcome measures, and the sample size. We
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ORIGINAL RESEARCH
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the risk for CHD among Chinese immigrants in comparison
with other population subgroups has not been systematically
reviewed. Furthermore, it remains unclear whether the
discordance between the incidence and prognosis of CHD
exists in Chinese immigrants, as the current evidence shows
conflicting results.12,14
This is the first study to systematically review and metaanalyze the incidence and prognosis of CHD among Chinese
immigrants living in Western countries. To quantify differential
risk and to contextualize findings, we compared Chinese
immigrants with whites and South Asians in the same host
country. Whites were selected because they are the most
common racial group in Western countries. South Asian
immigrants were selected because they are another fastgrowing population in Western countries and they feature
prominently in primary research studies included in this
review, having higher cardiac mortality rates than other ethnic
groups.15 Comparing incidence and prognosis of CHD with
the host population and another major migrant group will help
prioritize the related public health agenda and resource
allocation at different stages of CHD prevention, allowing for
the most effective and efficient programs and interventions to
improve CHD outcomes at the population level.16
A Chinese Immigrant Paradox? Systematic Review
Jin et al
Data Synthesis and Statistical Analyses
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An odds ratio (OR) with 95% CI was used to measure effect
size to compare the incidence and short-term outcomes of
CHD. Hazard ratios with 95% confidence were used to assess
the long-term outcome after diagnosis of CHD. Statistical
heterogeneity across the studies was tested using the I²
statistic between studies.24 I² values can be categorized as 0%
to 40% (might not be important); 30% to 60% (may represent
moderate heterogeneity); 50% to 90% (may represent substantial heterogeneity); and 75% to 100% (considered heterogeneous).24 When statistical heterogeneity exceeded 70%,
subgroup analysis was performed to explain the heterogeneity. If heterogeneity was deemed to be substantial, we also
performed a narrative summary. Analyses were conducted
using Comprehensive Meta-Analysis software, Version 2.0
(Biostat, Englewood, NJ; http://www.meta-analysis.com).
Results
Study Identification
The literature search identified 1424 potentially relevant
records. After excluding 686 duplicates, the remaining 738
records were screened based on reading the title and
abstract, which led to a further exclusion of 671 papers
(Figure 1). The remaining 67 papers were subject to a more
detailed review based on reading the full text, and of those, 31
papers remained. Ten additional papers were identified
through manual review of references. Of these 41 papers,
33 papers were excluded after detailed evaluation of these
articles, leaving a final 8 papers in our review12,14,25–30
(Table 1). All studies were cohort studies using registry data
that were dated from 1987 to 2010. Country of study
included Canada, the Netherlands, Sweden, Scotland, and the
United States. The diagnosis of CHD was defined by
International Classification of Diseases code in all studies.
Incidence of CHD in Chinese Compared With
Whites or South Asians
Of the 8 studies, 3 reported the incidence of CHD in Chinese
compared with whites and South Asians14,27,30 (Table 2). The
number of Chinese participants in each study ranged from
6254 to 192 155, with duration of follow-up ranging from 7 to
10 years. All 3 studies reported results separately for men
and women. For the meta-analysis, the results of Bansal
et al14 were split into 2 based on the outcome of AMI
DOI: 10.1161/JAHA.115.002568
incidence or mortality. Meta-analysis of all 3 populations in
these studies (226 795 Chinese with 994 events;
11 136 183 whites with 350 625 events; 113 846 South
Asians with 2536 events) showed that Chinese had a much
lower incidence of CHD compared with whites (OR, 0.29; 95%
CI, 0.21–0.40; I2=90%) and South Asians (OR, 0.34; 95% CI,
0.16–0.73; I2=97%). Subgroup analysis showed the OR of
incidence for whites was 0.29 (95% CI, 0.24–0.34; I2=74.5%)
and South Asians 0.37 (95% CI 0.24–0.57; I2=95%) (Figures 2
and 3). Although the heterogeneity between the analyzed
studies was high, the direction and magnitude of the
association based on the meta-analysis were consistent with
the adjusted incidence rates reported in each primary study
(Table 2).31
CHD Outcomes for Chinese, Whites, and South
Asians
Short-term mortality after first hospitalization for CHD
Four studies comparing Chinese with whites and South Asians
reported short-term death after first hospitalization for
AMI12,14,28,29. These came from 4 countries including Canada,
the Netherlands, Scotland, and the United States with followup periods ranging from 3 to 12 years (Table 3). Two studies
reported results separately for men and women.14,28 Three
studies12,14,29 reported total participants and death events
(total 1076 Chinese with 147 death events, 318 782 whites
with 59 681 events, and 2907 South Asians with 195 events).
One study28 reported OR for Chinese compared to whites.
A meta-analysis was performed to compare the risk of
death after diagnosis of CHD between Chinese and whites as
well as Chinese and South Asians. The random-effects
summary of OR for Chinese compared to whites was 1.34
(95% CI, 1.04–1.73; Figure 4) with low heterogeneity
(I2=18%). The OR for Chinese compared to South Asians
was 1.82 (95% CI, 1.33–2.50; Figure 5), also with low
heterogeneity (I2=23%).
Long-term outcomes after diagnosis of CHD: Chinese
compared with whites
A total of 3 studies12,26,29 reported both long-term mortality
and recurrent AMI after CHD in Chinese and whites with a
follow-up time from 9 to 12 years with the exception of 1
study that reported second MI only25 (Tables 4 and 5). We
were not able to compare Chinese with South Asians due to
the lack of data. Meta-analysis showed risks of death and
recurrent AMI in Chinese compared with whites were not
statistically different (hazard ratio, 1.41; 95% CI 0.74–2.70;
I2=81%; hazard ratio, 1.05; 95% CI 0.74–1.48; I2=54%,
respectively) with moderate to substantial heterogeneity
(Figures 6 and 7).
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ORIGINAL RESEARCH
defined short-term prognosis outcomes as in-hospital mortality or mortality within 30 days and long-term outcomes as
mortality or recurrent AMI beyond 30 days.
A Chinese Immigrant Paradox? Systematic Review
Jin et al
ORIGINAL RESEARCH
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Figure 1. Search, screening, and selection process of studies of incidence of CHD and outcome after
CHD for Chinese living in Western countries. CHD indicates coronary heart disease; ICD, International
Classification of Diseases.
Discussion
This systematic review and meta-analysis evaluated the
association between Chinese ethnicity and the incidence
and prognosis of CHD in Western countries. While Chinese
had much lower incidence of CHD, they had significantly
higher short-term mortality after first diagnosis of CHD
compared with whites and South Asians. This result is
consistent with a previous international study, which found
that AMI patients in China had a higher age-adjusted 28-day
case fatality rate compared with those in Australia, Canada,
and the United States.32 A similar finding was observed in an
analysis of more than 15 000 AMI patients in Singapore;
DOI: 10.1161/JAHA.115.002568
patients of Chinese ethnicity had the highest in-hospital
mortality rates compared with South Asians and Malays.33
This presents a potential “paradox” where the risk of incident
CHD and that of short-term mortality may be inconsistent.
Low incidence of CHD in Chinese immigrants may be
explained by their favorable behavioral risk profiles, such as
healthier diet, physical activity, and lower prevalence of
obesity and smoking compared with whites and South Asians,
as discovered by cross-sectional studies in Canada, the
United Kingdom, and the United States.2,34–36 It is possible
that poorer short-term survival in Chinese may not be
explained alone by age or proximity to the hospitals and
healthcare system. Although Chinese were older than South
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A Chinese Immigrant Paradox? Systematic Review
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ORIGINAL RESEARCH
Table 1. Characteristics of Included Studies
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Age Range
(Years)
Sex
Identification
of Ethnicities
Chinese
Whites
South Asians
≥30
M/F
Self-reported
First occurrence of admission or
death due to MI and time to event
1995–2007
Chinese
Whites
All ages
M*
Country of birth
Short-term and long-term mortality
after a first CABG
Sweden
1987–2007
Chinese
Whites
South Asians
≥30
M/F
Country of birth
Incidence of second MI
Khan et al (2010)12
Canada
1994–2003
Chinese
Whites
South Asians
≥20
M/F
Surname
identification
Short- and long-term mortality and
risk of nonfatal cardiac
complication
Nijjar et al (2010)27
Canada
1995–2002
Chinese
Whites
South Asians
≥35
M/F
Surname
analysis
Impact of ethnicity on revascularization
and mortality rates after ACS during
initial hospitalization
Taira et al (2001)28
United States
1997–1999
Chinese
Whites
Not
indicated
M/F
Self-reported
Impact of ethnicity on revascularization
and mortality rates after ACS during
initial hospitalization
Van Oeffelen
et al (2014)29
The Netherlands
1998–2010
Chinese
Whites
South Asians
Not
indicated
M/F
Country of birth
28-day and 5-year mortality and
readmission after first AMI
Van Oeffelen
et al (2015)30
The Netherlands
1997–2007
Chinese
Whites
South Asians
≥30
M/F
Country of birth
Incidence of MI
Study
Country
Period of Time
Study Population
Bansal et al (2013)14
Scotland
2001–2008
Dzayee et al (2013)26
Sweden
Dzayee et al (2014)25
Outcome
ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; CABG, coronary artery bypass grafting.
*No women death in the Chinese group.
Asians in this review, they had an age profile similar to whites.
In addition, both Chinese and South Asians were more likely
to live closer to hospitals compared with whites.12,29
Despite the limited data, due to the small number of
available studies and particularly small samples of Chinese
immigrants, several factors may explain the likely higher
short-term mortality after CHD in Chinese. First, Chinese are
less likely to have typical AMI symptoms (eg, midsternal pain
and/or midsternal pressure),37 which could contribute to
underdiagnosed heart disease leading to delay in definitive
treatment and increased myocardial injury severity. Second,
reporting of atypical symptoms is found to increase with
age.37 Although both Chinese and South Asians are reported
to have less typical AMI symptoms compared with whites,37 in
this review, Chinese immigrants with AMI are much older than
South Asians and this may exacerbate the diversity of
presenting symptoms in this group.
Furthermore, Chinese patients have been found to have
higher rates of cardiac catheterization within 1 day of AMI
(22.8%, 15.3%, and 16.5% respectively) and percutaneous
coronary intervention (27.6%, 18.1%, and 17.3%, respectively)
compared with whites and South Asians.12 These results
suggest Chinese patients may have more severe infarcts
DOI: 10.1161/JAHA.115.002568
compared with other patients.38 This could be due to delayed
medical attention and treatment, resulting in an unsuccessful
response to thrombotic therapy or other treatments.12,38 The
much lower incidence of CHD in Chinese compared with
whites could also reflect poor data capture due to lower
health literacy among Chinese immigrants; reduced awareness of heart disease may mean Chinese are less likely to
recognize AMI symptoms compared to whites.37,39
Additionally, unsatisfactory control of risk factors subsequent to reduced medication adherence in Chinese immigrants may contribute to higher risk of mortality after CHD.
One study from China found that history of hypertension was
associated with 28-day mortality after AMI in men.40 Poor
adherence to evidence-based antihypertensive medication
among Chinese people was found to relate to their cultural
preference for traditional medicine.41,42 Chinese immigrants
were found to have the highest prevalence of alternative
medicine use compared with other Asian ethnic groups.43 The
common use of herbs such as garlic, ginseng, and ginkgo in
Chinese culture37,44 can also lead to bleeding, a serious
complication of percutaneous coronary diagnostic or interventional procedures.45 Furthermore, some studies suggest
that Chinese patients may have different pharmacogenetic
Journal of the American Heart Association
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135/4360
20/2216
147 500/3 178 693
93 574/3 447 537
81/4261
41/4125
AMI
1997–2007
Nationwide
registers in
the
Netherlands
Van
Oeffelen
et al
(2015)30
AMI
1995–2002
Hospital data
from
BC, Canada
Nijjar
et al
(2010)27
DOI: 10.1161/JAHA.115.002568
AMI indicates acute myocardial infarction; CHD, coronary heart disease; IQR, interquartile range.
*Age standardized to Caucasians incidence rate/100 000.
†
Age-standardized rate/1000 years.
349*
159*
M:190*
F: 127*
Median (IQR)
M:50 (40–63)
F:52 (40–67)
Median (IQR)
M:46 (38–55)
F:44 (36–54)
Median (IQR)
M:40 (35–45)
F:39 (35–45)
403*
131*
1383/43 790
561/44 175
21 277/909 870
10 807/978 735
545/89 350
279/102 805
3.29†
1.53†
M:0.98†
F: 0.49†
>35
>35
>35
4.97†
2.35†
314/10 193
123/9112
43 498/1 212 686
33 969/1 408 662
27/3004
21/3250
620.9*
425.5*
>30
AMI
National data
in Scotland
Bansal
et al
(2013)14
2001–2008
>30
>30
512.4*
344.5*
Whites
Chinese
South
Asians
Whites
Chinese
Disease
Outcome
Period of
Time
Data Sources
Study
Incidence Rates
Age Range (Year)
Ethnic Group
M:230.9*
F: 245.6*
Whites
Chinese
South
Asians
Number of Cases/Total Participants
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Table 2. Studies on Incidence of CHD
Jin et al
responses to antiplatelet or anticoagulant therapy, which
could potentially contribute to the higher risk of short-term
mortality among Chinese participants. Research has shown
that clopidogrel resistance, associated with significantly
higher risk of major cardiovascular events such as bleeding,
MI, and death, was 68% to 73% among Chinese immigrants
compared with 5% to 44% among the mainstream Western
population.46,47 Warfarin response variability also exists
among Chinese patients, leading to a higher risk of bleeding
events compared to whites.48
Underutilization of healthcare services by Chinese immigrants has also been documented in the literature.49,50
Language barriers may cause delay in seeking early medical
advice and treatment. One Canadian study showed Chinese
immigrants are the least likely to speak fluent English
compared with other ethnic groups, such as South Asians.37
Poor English is also associated with poor uptake of health
check-ups, such as for lipid screening.51 Due to the collective
nature of Chinese culture, older Chinese people are usually
quieter and more stoic and less likely to voice symptoms or
discuss treatment with doctors.49 Finally, physician bias could
impact on diagnosis and management if the doctors are
unaware of ethnic variations in AMI symptoms and CHD risk
factors among Chinese patients.37
Interestingly, in our study, outcome findings for South
Asians were in contrast: having higher incidence but lower
short-term mortality compared to Chinese and whites, which
is consistent with previous research.16 The better survival
rates found in the South Asian population may suggest
doctors’ awareness of their increased coronary risk and better
cardiac disease management for South Asians, including
changes in health behaviors after AMI and better community
support.12,16
Strength and Limitations
A major strength of this study is the robust and systematic
nature of the evidence synthesis. Our meta-analysis of the
prognosis after CHD may be particularly important in
identifying Chinese immigrants as a unique “at risk” subgroup
of patients. Another strength is the homogeneous nature of
our study design: there is consistency among the included
studies in administrative data sources covering broad populations, in settings (high-income countries dominated by
European culture), in population selection, outcome measures, and in the similarity of universal health systems (with
the exception of the United States), especially for the studies
of prognosis. Our use of International Classification of
Diseases codes to define CHD avoided the bias of using
self-reported heart disease in survey studies.
The limitations of this review are related to the included
primary studies. First, there are a small number of Chinese
Journal of the American Heart Association
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South Asians
A Chinese Immigrant Paradox? Systematic Review
A Chinese Immigrant Paradox? Systematic Review
Jin et al
ORIGINAL RESEARCH
Figure 2. Incidence of coronary heart disease in Chinese compared with whites.
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participants compared with whites in most of the studies.
However, this meta-analysis was based on the available data
from national or state registry data sets, which are more
generalizable. Second, the short-term mortality result between
Chinese and whites is largely driven by Khan’s study12 which
had a much larger sample of Chinese immigrants than other
studies. While bias in the direction of overestimating the risk
cannot be eliminated if all results are used, with the exception
of Bansal14 (2013), the other ORs were in the direction of higher
risk; however, only Khan’s study12 (2010) appears to have been
adequately powered to detect the OR at a statistically
significant level. Our results should stimulate further research
with robust strategies. Third, the use of hospital data in the
prognostic studies limits participants to those with a diagnosis
of CHD, and may exclude those who may be misdiagnosed or
die before coming to the hospital. Fourth, significant hetero-
geneity was noted in the analysis of incidence of CHD. However,
the results of I2 for heterogeneity need to be interpreted with
caution when there are only limited studies included in the
meta-analysis. In this analysis, only 3 studies were included and
we had performed random-effects meta-analysis to incorporate
heterogeneity among studies. Moreover, the demographics,
follow-up duration, outcome measurement, and study quality
were similar across the studies. Finally, the definition of
ethnicity in this meta-analysis was not standardized and may
involve misclassification. Bias could have been introduced by
defining Western-born Chinese as whites when country of birth
was used as a proxy for ethnicity. Surname analysis could also
misclassify ethnic categories.12,16 In most cases, misclassification should involve defining Chinese immigrants as whites
and therefore may underestimate the differences between
them.
Figure 3. Incidence of coronary heart disease in Chinese compared with South Asians.
DOI: 10.1161/JAHA.115.002568
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DOI: 10.1161/JAHA.115.002568
30-day mortality
during the first
hospitalization
for AMI
In-hospital
mortality after
ACS during the
initial
hospitalization
Khan et al
(2010)12
Canada
Taira et al
(2001)28
United States
1998–2010
1997–1999
1994–2003
2001–2008
Follow-Up
Period
Total
M
F
Total
Median
age
(IQR)
Mean age
<50
50 to 64
65 to 74
>75
68
(57–75)
7111
7.4
23.6
29.8
39.2
69
(58–78)
6911
9.7
27.3
26.8
36.2
South
Asians
Chinese
M: 70.7
F: 37
—
51
(46–57)
F: 33.7
12.9
35.6
27.2
24.3
66.0
31
33.2
Whites
89.6
—
28.3
South
Asians
Chinese
11/82
—/158
—/91
116/946
7/21
Whites
F
Chinese
13/27
Age
20 471/202
836
—/390
—/179
3321/38
479
17 159/33
969
18 730/43
498
Whites
No. of Death/Total Participants
M
Sex
Gender (%)
ACG indicates adjusted clinical group; ACS, acute coronary syndrome; AMI, acute myocardial infarction; CHD, coronary heart disease; IQR, interquartile range; SES; socioeconomic status.
28-day mortality
after first AMI
hospitalization
28-day mortality
of first AMI
Bansal et al
(2013)14
Scotland
Van Oeffelen
et al (2014)29
The
Netherlands
Disease Outcome
Study/Country
Age (%)
Ethnic Group
12/280
—
—
170/2190
36/123
94/314
South
Asians
Age, sex,
marital status,
degree of
urbanization,
and year of
event
Age, diabetes
mellitus,
congestive
heart failure,
acute
myocardial
infarction,
ACGmorbidity
level, and
system care
Age, sex, SES,
geographic
distance,
hospital with
revascularization
capacity,
province, year
of AMI, and
comorbid
conditions
Age, travel
time, and
intervention
Adjustments
ORIGINAL RESEARCH
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Table 3. Studies on Short-Term Mortality After CHD in Chinese, White, and South Asians
A Chinese Immigrant Paradox? Systematic Review
Jin et al
Journal of the American Heart Association
8
A Chinese Immigrant Paradox? Systematic Review
Jin et al
ORIGINAL RESEARCH
Figure 4. Short-term mortality in Chinese compared with whites.
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Figure 5. Short-term mortality in Chinese compared with South Asians.
Table 4. Studies on Long-Term Mortality After CHD
Mortality After CHD
HR (95%)
No. of Deaths
Country/Data Sources
Period of Time
Disease Outcome
Chinese Versus Whites
Chinese
Whites
Sweden/National
registers
1995–2007
Short- and long-term
mortality after a first CABG
3.61 (1.5, 8.6)*
5
10 220
Khan et al (2010)12
Canada/Data from
BC & Alberta
1994–2003
Long-term mortality after first
hospitalization for AMI, recurrent AMI
0.89 (0.77, 1.0)
—
—
Van Oeffelen
et al (2014)29
Netherlands/Nationwide
registers
1998–2010
5-year mortality and AMI readmission
after first AMI
1.29 (0.77, 2.18)
14
35 337
Study
Dzayee et al (2013)
26
AMI indicates acute myocardial infarction; CABG, coronary artery bypass grafting; CHD, coronary heart disease; HR, hazard ratios.
*Male only.
DOI: 10.1161/JAHA.115.002568
Journal of the American Heart Association
9
A Chinese Immigrant Paradox? Systematic Review
Jin et al
ORIGINAL RESEARCH
Table 5. Studies on Recurrent AMI After CHD
Recurrent AMI
Study
HR (95%)
No. of Events
Chinese Versus
Whites
Chinese
Whites
Country/Data Sources
Period of Time
Disease Outcome
Sweden/National registers
1987–2007
MI occurring more than
28 days after first MI
1.03 (0.53, 1.9)
9
38 218
Khan et al (2010)12
Canada/Data from BC & Alberta
1994–2003
Long-term mortality after
first hospitalization for AMI,
recurrent AMI
0.8 (0.65, 0.9)
—
—
Van Oeffelen
et al (2014)29
Netherlands/Nationwide registers
1998–2010
5-year mortality and AMI
readmission after first AMI
1.77 (0.66, 4.7)
<10
6029
Dzayee et al (2014)
25
AMI indicates acute myocardial infarction; CHD, coronary heart disease; HR, hazard ratios.
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Figure 6. Long-term mortality in Chinese compared with whites.
Figure 7. Recurrent acute myocardial infarction in Chinese compared with whites.
DOI: 10.1161/JAHA.115.002568
Journal of the American Heart Association
10
A Chinese Immigrant Paradox? Systematic Review
Jin et al
As compared with whites and South Asians, Western-dwelling
Chinese immigrants showed a lower incidence of CHD, but a
potentially poorer prognostic outcome after initial CHD
diagnosis, hence a potential “Chinese immigrant paradox.”
The poor short-term survival after CHD in Chinese immigrants
may be explained by genetic differences, cultural habits, and
acculturation. More rigorous research is required to monitor
and compare short-term survival outcomes of population
subgroups that may be at higher risk. Public health efforts
should focus on early secondary prevention in this population
to reduce mortality and reoccurrence from secondary events
in the first 30 days. Ethnic variations in AMI presentation and
disease management should be considerations for healthcare
providers caring for Chinese patients.
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Sources of Funding
Kai Jin is supported by Postgraduate Research Support
Scheme, Sydney Nursing School, University of Sydney. Dr
Ding (APP1072223) and Dr Neubeck (APP1036763) are
funded by early career fellowships from the National Health
and Medical Research Council of Australia. The funding
sources had no involvement in the analysis presented here.
Disclosures
None.
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Supplemental Material
Appendix 1
Key words for searching literature
Chinese
Migrant/migrat*
Cardiovascular,
China
Immigrant/immigrat*
“heart disease”,
Hong Kong
Emigrant/emigrat*
Angina
Taiwan
Refugee
Circulatory,
Macau
Expatriate
Cerebrovascular,
Relocat*
Stroke
Acculturat*
“Myocardial infarction”,
coronary,
“heart attack”,
heart surgery
Appendix 2
Search Strategies
Pubmed:
#4,"Search (cardiovascular[Title/Abstract]) OR angina[Title/Abstract])
OR ""heart disease""[Title/Abstract])
OR circulatory[Title/Abstract])
OR cerebrovascular[Title/Abstract])
OR stroke[Title/Abstract])
OR coronary[Title/Abstract])
OR ""heart attack""[Title/Abstract])
OR ""myocardial infarction""[Title/Abstract]))
AND (migrant*[Title/Abstract])
OR migrat*[Title/Abstract])
OR immigrant*[Title/Abstract])
OR immigrat*[Title/Abstract])
OR emigrant*[Title/Abstract])
OR emigrat*[Title/Abstract])
OR refugee[Title/Abstract])
OR expatriate[Title/Abstract])
OR relocat*[Title/Abstract]) OR acculturat*[Title/Abstract]))
AND (Chinese[Title/Abstract])
OR China[Title/Abstract])
OR Hong Kong[Title/Abstract])
OR Taiwan[Title/Abstract])
OR Macao[Title/Abstract])
OR Macau[Title/Abstract])",138,01:07:38
#3,"Search (cardiovascular[Title/Abstract])
OR angina[Title/Abstract])
OR ""heart disease""[Title/Abstract])
OR circulatory[Title/Abstract])
OR cerebrovascular[Title/Abstract])
OR stroke[Title/Abstract])
OR coronary[Title/Abstract])
OR ""heart attack""[Title/Abstract])
OR ""myocardial infarction""[Title/Abstract]",847264,01:04:38
#2,"Search (migrant*[Title/Abstract])
OR migrat*[Title/Abstract])
OR immigrant*[Title/Abstract])
OR immigrat*[Title/Abstract])
OR emigrant*[Title/Abstract])
OR emigrat*[Title/Abstract])
OR refugee[Title/Abstract])
OR expatriate[Title/Abstract])
OR relocat*[Title/Abstract])
OR acculturat*[Title/Abstract]",245868,00:30:34
#1,"Search (Chinese[Title/Abstract])
OR China[Title/Abstract])
OR Hong Kong[Title/Abstract])
OR Taiwan[Title/Abstract])
OR Macao[Title/Abstract])
OR Macau[Title/Abstract]",208345,00:22:25
A Chinese Immigrant Paradox? Low Coronary Heart Disease Incidence but Higher Short−
Term Mortality in Western−Dwelling Chinese Immigrants: A Systematic Review and Meta−
Analysis
Kai Jin, Ding Ding, Janice Gullick, Fung Koo and Lis Neubeck
Downloaded from http://jaha.ahajournals.org/ by guest on June 17, 2017
J Am Heart Assoc. 2015;4:e002568; originally published December 18, 2015;
doi: 10.1161/JAHA.115.002568
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The online version of this article, along with updated information and services, is located on the
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Subscriptions, Permissions, and Reprints: The Journal of the American Heart Association is an online only Open
Access publication. Visit the Journal at http://jaha.ahajournals.org for more information.
Supplemental Material
Appendix 1
Key words for searching literature
Chinese
Migrant/migrat*
Cardiovascular,
China
Immigrant/immigrat*
“heart disease”,
Hong Kong
Emigrant/emigrat*
Angina
Taiwan
Refugee
Circulatory,
Macau
Expatriate
Cerebrovascular,
Relocat*
Stroke
Acculturat*
“Myocardial infarction”,
coronary,
“heart attack”,
heart surgery
Appendix 2
Search Strategies
Pubmed:
#4,"Search (cardiovascular[Title/Abstract]) OR angina[Title/Abstract])
OR ""heart disease""[Title/Abstract])
OR circulatory[Title/Abstract])
OR cerebrovascular[Title/Abstract])
OR stroke[Title/Abstract])
OR coronary[Title/Abstract])
OR ""heart attack""[Title/Abstract])
OR ""myocardial infarction""[Title/Abstract]))
AND (migrant*[Title/Abstract])
OR migrat*[Title/Abstract])
OR immigrant*[Title/Abstract])
OR immigrat*[Title/Abstract])
OR emigrant*[Title/Abstract])
OR emigrat*[Title/Abstract])
OR refugee[Title/Abstract])
OR expatriate[Title/Abstract])
OR relocat*[Title/Abstract]) OR acculturat*[Title/Abstract]))
AND (Chinese[Title/Abstract])
OR China[Title/Abstract])
OR Hong Kong[Title/Abstract])
OR Taiwan[Title/Abstract])
OR Macao[Title/Abstract])
OR Macau[Title/Abstract])",138,01:07:38
#3,"Search (cardiovascular[Title/Abstract])
OR angina[Title/Abstract])
OR ""heart disease""[Title/Abstract])
OR circulatory[Title/Abstract])
OR cerebrovascular[Title/Abstract])
OR stroke[Title/Abstract])
OR coronary[Title/Abstract])
OR ""heart attack""[Title/Abstract])
OR ""myocardial infarction""[Title/Abstract]",847264,01:04:38
#2,"Search (migrant*[Title/Abstract])
OR migrat*[Title/Abstract])
OR immigrant*[Title/Abstract])
OR immigrat*[Title/Abstract])
OR emigrant*[Title/Abstract])
OR emigrat*[Title/Abstract])
OR refugee[Title/Abstract])
OR expatriate[Title/Abstract])
OR relocat*[Title/Abstract])
OR acculturat*[Title/Abstract]",245868,00:30:34
#1,"Search (Chinese[Title/Abstract])
OR China[Title/Abstract])
OR Hong Kong[Title/Abstract])
OR Taiwan[Title/Abstract])
OR Macao[Title/Abstract])
OR Macau[Title/Abstract]",208345,00:22:25